2. William Harwey (1578-1657)
• Hemodymamics
• Discovery of blood circulation and heart
function (published 1628)
• This theory was fully accepted after
discovery of pulmonary capillaries
(Marcello Malpighi - 1661).
11. Diastolic work the
filling blood (made on
the heart)
Systolic work
of the heart
Intraventricular
pressure
Ventricular volume
afterload
Stroke
volume
Systolic
residual
volume
Enddiastolic
volume
preload
23. Symptoms of Cardiovascular
Diseases
Chest pain or discomfort
Dyspnea (abnormally uncomfortable awareness of
breathing)
Palpitations (uncomfortable awareness of beating
of the heart)
Syncope
Peripheral edema
Claudication
24.
25. • Measurement and evaluation of volume and pressure provide
information about the cardiovascular system function.
• The cardiovascular system transports volume (blood) between
individual body compartments
• Blood pressure is necessary to maintain proper blood flow
• to form pressure gradient between heart and the periphery
• to overcome the peripheral resistance.
Ohm’s law
Q (flow) = P (pressure gradient) / R (resistance)
Principles in hemodynamics
evaluation
26. Principles in hemodynamics
evaluation
Blood volume and pressure influence heart
and vessels anatomy
–changes which are important for the
function of cardiovascular system
• heart muscle dilatation
• heart muscle hypertrophy
• Increase in vessel resistance (organ,
systemic, temporary, permanent)
31. Ejection fraction (EF)
• Basic parameter for evaluation of the
systolic function of the heart
• Decreased: decreased contractility (CHD,
heart failure), valvular diseases,
• Increased: hypertrofic cardiomyopathy
32. Normal values:
50–55 % and more
increased e.g. due to sympathetic stimulation and
other inotropic action
40 % and less in systolic dysfunction
Measurement:
most commonly by echocardiography, ev. isotope methods
Ejection fraction (EF)
39. Calculate and comment EF
• Left ventricle has at the end of the diastole
volume of 145 mL. Cardiac output is 4,8
L/min. Heart rate is 90/min.
40. Calculate and comment EF
• EDV = 145 ml
• SV = ?
• CO = 4800 mL/min
• HR = 90/min
• SV = CO / HR = 4800 / 90 = 53,3 mL
• EF = 53,3 / 145 = 0,37 (37 %)
41. Calculate and comment EF
• Cardiac output is nearly normal
• Mild tachycardia
• Increased preload
• Decreased EF
Decreased effectivness of the systole is
compensated by the increase of preload
and tachycardia
42. Cardiac output, cardiac index
CO = HR × SV
(HR = heart rate, SV = stroke volume)
• Normal values: 4–7 L/min
CI = CO/body surface
• Normal values: 2.8 – 4.2 L/m2
Measurment:
• Thermodilution (standard) – Swan-Ganz catheter
– Fick Principle
• Noninvasive methods (Echo with Doppler)
43. Thermodilution method
• The applies indicator dilution principles using
temperature change as the indicator
• A known amount of solution at a known
temperature is injected rapidly into the right atrial
lumen of the catheter.
• This cooler solution mixes with and cools the
surrounding blood, and the temperature is
measured downstream in the pulmonary artery by
a thermistor embedded in the catheter.
• The resultant change in temperature is then
plotted on a time-temperature curve
44. Venous return
(Preload) myocardium
Fluid volume
venous tonus
breathing
Muscle pump
EDV ESV
SV
EF
Vessel resistance
(afterload) Cardiac output
Heart rate
Sympatic n.
contractility
Systolic Function of Heart
Sympatic n.
Renin-Angiotensin-Aldisteron
46. Blood Pressure
• Measured in millimeters of
mercury (or kPa), within
the major arterial system of
the body
• Systolic pressure
– maximum blood pressure
during contraction of the
ventricles
• Diastolic pressure
– minimum pressure recorded
just prior to the next
contraction
47. Blood Pressure
• The blood pressure is
usually taken with the
patient seated using
standard blood pressure cuff
• Additional information may
be gained by checking the
patient in the lying and
standing positions
– Systolic blood pressure should
not drop more than 10 mm Hg,
and diastolic pressure should
remain unchanged or rise
slightly.
48. Systemic BP
• systolic: heart function
• diastolic: peripheral resistance
• mean pressure
• pressure amplitude
• hypertension, hypotension
49. Interpretation of Blood Pressure Measurements
in
Individuals 18 Years of Age and Older
Diastolic pressure (mm
Hg)
Category
<85 Normal
85-89 High normal
90-104 Mild hypertension
105-114 Moderate hypertension
>115 Severe hypertension
Systolic pressure (mm
Hg) (when diastolic < 90)
Category
< 140 Normal
140-159 Borderline isolated systolic hypertension
>160 Isolated systolic hypertension
50. Pressures in the heart
Atria
• Pressure practically depends on the pressure
in the ventricles if the valves are intact
• Pressure gradients (atrium – ventricle)
– valves open, the pressure in the atrium and
ventricle is equal in diastole
– difference originates due to valve stenosis
– the gradient reflects the tightness of stenosis
51. Pressures in the heart - Ventricles
(chambers)
Diastole
• during filling of the ventricles the pressure
increases, the increase depends on
compliance of the ventricle and in normal
heart the increase is only weak
Systole:
• pressure depends on heart contraction and
pressure in aorta/pulmonary artery
52. Invasive measurement of BP
– pressure measurements in separate heart
cavities
– wedge pressure – end-diastolic pressure
– pressure gradients
– cardiac output
– blood for oxygen saturation
– Injection of contrast dyes for angiography
– biopsy
55. Heart catheterization
• Swan-Ganz catheter position in heart
– Right atrium (RA)
– Right ventricle (RV)
– Pulmonary artery (PA)
– Pulmonary artery wedge pressure (PAWP)
56. Pressure tracing during catheterization
by Swan-Ganz catheter
right atrium – RA
right ventricle (RV)
pulmonary artery (PA)
PAWP
PCW
• reflect the pressure in
left atrium / ventricle (in
absence of mitral
stenosis)
• increase in
• left heart failure
• mitral stenosis
57. End-diastolic pressure
• the pressure in the ventricle at the end of diastole
• depends on filling (volume, preload) and
myocardial wall properties (compliance)
Normal values: 6-12 mmHg
Measurement:
• performed as (pulmonary capillary) wedge
pressure during catheterization
• P(A)WP – pulmonary (artery) wedge pressure or
PCWP – pulmonary capillary wedge pressure
58. Central venous pressure (CVP)
• The pressure of blood in the right atrium
• Swan-Ganz catheter or other
• Normal values: 2-8 mm Hg
• Monitoring of systemic volume filling
• CVP indirectly indicates the efficiency of the
heart's pumping action (EDP RV, if not
tricuspidal stenosis)
• Decreased due to hypovolemia,
• Increased due to hypervolemia, right heart
failure, tricuspidal stenosis
59. Pressure values
• pulmonary artery systolic pressure is 15 to 30
mmHg
• pulmonary artery mean pressure is 9 to 17 mmHg
(normal < 20 mmHg)
• pulmonary artery diastolic pressure is 0 to 8 mmHg
• pulmonary capillary wedge pressure is 5 to 12
mmHg (mean <12)
• right atrial pressure is 0 to 8 mmHg
60. Pressures in pulmonary
circulation
a. pulmonalis: 20 (30)/12/15 (20)
vv. pulmonales
lung capillaries
7-8
left atrium 1-5 (až 12) mm Hg
right ventricle
20/1
systolic /diastolic/mean/borderline
61. DIASTOLE SYSTOLE
BPd atr.
BPd ventr.
BPs atr.
BPs ventr.
BPd atrium =BPd ventricle
Pressures in atrium and
ventricle
64. Pressures in heart valve
diseases
Mitral stenosis
• Simultaneous recording of pressures
in the pulmonary artery wedge
position (PAW) and the left ventricle
(LV)
• large gradient in diastole across the
mitral valve. The PAW pressure is
markedly elevated.
• Increased pressure in LA improves
diastolic flow to LV, LA
hypertrophies etc.
• Increased PAW may lead to
pulmonary edema
65. Pressures in heart valve
diseases
Mitral regurgitation
• increase of pressure in LA
during ventricle contraction
(part of the blood returns to the
atrium)
LA dilation and hypertrophy
66. • due to stenosis the pressure in LV
increases and becomes higher than
pressure in aorta (Ao)
• pressure gradient results
(normally both pressure peaks equal)
• important hypertrophy of LV
Pressures in heart valve
diseases
Aortic stenosis
67. Pressures in heart valve
diseases
Aortic regurgitation
• due to backward flow the aortic
pressure declines more rapidly
• to compensate (to maintain
normal mean pressure)
systolic pressure increases
• increased pressure amplitude
68. Case Study – KVS1
• M 23 yr., admitted to the hospital for
malignant hypertension.
• DM from 8 yr. of age fail to take insulin and
diet
• fail to take anti-hypertension medication
• 1 wk. before the admission was tired,
blurred vision, vomiting.
• 12 h before the admission speech failure
• BP 220/140, No orthostatic
• Edema of lower extremities
Case Study – KVS1
69. Ophthalmologic evaluation: bilateral edema
of papilla with hemorrhages and exudates,
arterial vasoconstriction.
Note the hard exudates in white, the hemorrhages in red, and the blurred disk margin.
This is grade four hypertensive retinopathy.
Hypertensive retinopathy (grade IV)
Case Study – KVS1
70. Laboratory
• - hyperkaliemia
• - low bicarbonates
• - creatinin 20.3 mg/dl (high)
• - proteinuria
• - hematuria (40-50 RBC per high power
field.)
Case Study – KVS1
86. Laboratory tests
Diagnosis of acute myocardial infarction:
(necrotic tissue and the reaction of the organismu)
-CK-MB,
-AST,
-LD,
-myoglobin,
-troponins,
-leucocytes,
-FW
BNP (brain natriuretic peptide) in heart failure
87. Fick principle
To measure oxygen consumption or cardiac output (CO)
blood flow in the lung
consumption O2 = --------------------------------------------
arterial O2 - venous O2
consumption of O2
CO = ---------------------------------------------------
AV difference
Example:
1 L of arter. blood contains cca 200 mL of oxygen, 1 L of mixed ven. blood 150 mL.
AV difference is thus 50 mL/L of blood. These values can be determined by
catheterization and oxygen measurment.
Oxygen consumption in 1 min is 250 mL (measurement of estimation,
e.g. 3 mL O2/min/kg or 125 mL/min/m2).
CO is in this case 250/50, i.e. 5 L per minute.
88. VO2 = VE × (FiO2 - FeO2)
VE – minutová ventilace
Fi – inspirační frakce
Fe – exspirační frakce
89. Bude-li SV nízký – zhoršená perfuze orgánů
-únava
-slabost
-nízké prokrvení ledvin --- aktivace systému RAA
ALDOSTERON
retence Na+
ANGIOTENZIN II
vazokonstrikce
snížení GF
mitogenní účinky na srd. sval
